Makindo Medical Notes

🔗 Related Subjects: | Osteomalacia – Rickets – Vitamin D

🦴 About

• Fractures occur in around 20% of children following injury.
• Lifetime risk of a fracture before age 16: Boys 42%, Girls 27%.
• Common sites: Distal radius, hand, elbow, clavicle, radius, tibia.

⚙️ Aetiology

• 💡 The epiphysis is the site of bone elongation and fuses in adulthood.
• 🧒 Children’s bones can absorb more energy before fracturing — they bow rather than break.
• 🩸 Excellent vascular supply → rapid healing and strong remodelling potential.
• ⚽ Mechanisms: sports injuries, falls, bike accidents, and road traffic collisions.
• 🥛 Risk increased by poor nutrition, calcium deficiency, or vitamin D deficiency.

🔢 Types of Fractures in Children

• Single, non-displaced
• Transverse
• Oblique
• Spiral
• Comminuted (multiple fragments)
• Segmented
• Avulsion (chip of bone pulled off by tendon/ligament)
• Impacted
• 🔵 Torus fracture: buckling of cortex without complete break
• 🟢 Greenstick fracture: one cortex broken, the other intact
• 🔴 Open fracture: bone communicates with the exterior through the skin

🦵 Common Fracture Sites

• Clavicle: Middle third (80%); due to FOOSH, shoulder fall, or direct blow.
• Humerus: Midshaft rare; distal humeral (supracondylar) fractures common.
• Elbow: ~10% of all paediatric fractures; often supracondylar — immobilise before X-ray to prevent neurovascular injury. Flexion 20–30° minimises nerve tension.
• Radius/Ulna: Common after FOOSH; both bones often fractured together.
• Distal Radius: Most common childhood fracture; peaks at growth spurts (Boys 13–14, Girls 11–12).
• Wrist: Carpal fractures rare under age 12; scaphoid fractures seen in adolescents.
• Hand: Phalangeal/metacarpal injuries due to crush, twist, or sports trauma.
• Tibia/Fibula: Often occur together; twisting or fall mechanism.
• Toddler’s fracture: Spiral tibial fracture in <3-year-olds learning to walk; often subtle, child refuses to weight-bear.
• Ankle: Sports or play injuries — inversion/eversion strains common.
• Foot: Minor in most cases; calcaneal or tarsal fractures after falls.

📊 Fractures Through the Epiphysis – Salter-Harris Classification

• ⚽ Mechanism: Usually sports injuries but may occur in abuse, metabolic or neurological disorders.
• Type I: Through the physis only — epiphysis separates from metaphysis.
• Type II: Through the metaphysis and physis (most common).
• Type III: Through physis and epiphysis — intra-articular (e.g. Tillaux fracture).
• Type IV: Through metaphysis, physis, and epiphysis — risk of growth arrest.
• Type V: Crush injury of growth plate → poor prognosis, may cause bone growth arrest.
• 📉 Rare higher types (VI–IX) involve periosteum or metaphyseal bone loss.

🩺 Clinical Assessment

• Take careful history: mechanism, timing, and consistency with developmental stage.
• ⚠️ Always consider non-accidental injury — pattern, delay in presentation, inconsistent story.
• Inspect for swelling, redness, deformity, or open wounds.
• Compare to opposite limb.
• Assess joints above and below.
• Check neurovascular status (sensation, pulses, capillary refill).
• Test active and passive movement — pain and restriction guide location.

🔬 Investigations

• 🧫 Bloods: Calcium, phosphate, vitamin D (if osteomalacia/rickets suspected).
• 🩻 Radiology:
  • Request precise region — forearm ≠ wrist ≠ hand.
  • Always correlate clinically; imaging is not a substitute for examination.
  • Follow-up X-rays as bone may remodel or displacement may become visible later.

⚕️ Management Principles

• 🦵 Children heal rapidly due to active periosteum; most fractures treated with casting or splinting.
• 🔩 Severe or displaced fractures may require internal fixation (plates/screws).
• 🧬 Growth plate injuries risk deformity or limb-length discrepancy → careful long-term follow-up.
• Re-examine in 7–10 days; repeat radiographs at 6–12 months if growth arrest suspected.
• 🚨 Entrapped periosteum may prevent reduction — MRI may be needed.

🔩 Management by Salter-Harris Type

• Type I–II: Closed reduction + cast/splint.
• Type III–IV: Open reduction and internal fixation (avoid crossing physis).
• Type V: Often missed initially; poor prognosis; refer urgently to orthopaedics.

📚 References

• RCPCH Trauma & Safeguarding Guidance
• British Orthopaedic Association – Paediatric Fractures
• Radiopaedia: Salter-Harris Classification

💡 Teaching tip: Children’s bones are resilient but still vulnerable — they bend before they break, and remodel rapidly once aligned. Always think “growth plate, mechanism, and safeguarding.” 🧠